FIGURE 2 Overall survival of patients with hepatocellular carcinoma and gross portal vein tumor thrombus, grouped according to whether they underwent a hepatic resection. The difference in survival rates was statistically significant (P < 0.0001 for cirrhosis). Abbreviation: TACE, transarterial chemoembolization. Source: From Ref. 17.

FIGURE 3 Intrahepatic metastasis in segment 4 (arrow) detected on a lipiodol-computed tomography image taken 2 weeks after the injection of lipiodol.

detection of small but moderately to poorly differentiated nodules (21) (evidence Level 2b). Intraoperative ultrasonography (IOUS) is also highly sensitive and should be routinely performed. It is not uncommon to detect new hepatic nodules using IOUS during a hepatic resection for HCC (22). IOUS is also sensitive in detecting vascular invasion, such as the presence of a tumor thrombus in the portal or hepatic veins (Fig. 4) (evidence Level 4).

The presence of extrahepatic lesions, including lung metastasis, bone metastasis, and lymph node metastasis, are generally contraindications for liver resection, and patients with advanced HCC should be examined for extrahepatic lesions prior to undergoing surgery. Full-body CT imaging is recommended to check for lung and lymph node metastases. When enlarged lymph nodes are visualized in the retropancreatic, diaphragmatic, or para-aortic regions, these lymph nodes should be biopsied before liver resection (Fig. 5).

The diagnostic accuracy of bone scintigraphy in patients with HCC has been questioned because bone scintigraphy has not been routinely performed in HCC patients with a low likelihood of bone metastasis. Maillefert et al. reported a bone-metastasis detection rate of 67% using "mTc-MDP (methylene diphosphonate) scintigraphy and suggested that other agents taken up specifically by hepatocytes, like technetium 99m pyridoxyl-methyltryptophan (23) might also be useful. Lee et al. recently reported that 99mTc-MDP scintigraphy was highly sensitive in detecting bone metastasis in high-risk patients who were symptomatic or who had an elevated serum alpha-fetoprotein level (Fig. 6) (24) (evidence Level 4).

Preliminary reports have suggested that positron emission tomography (PET) is not useful for the detection of occult HCC in high-risk patients, such as those with hepatitis

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